The miracle cure? Exploring a public health approach to serious youth violence

Key:

• HM: Helen McKenna

• MG: Martin Griffiths

• KM: Karen McClusky

HM:    Hello and welcome to The King’s Fund podcast, where we talk about the big issues and ideas in health and care.  I’m Helen McKenna.  I’m a Senior Fellow here at The King’s Fund and I’m your host for today’s episode.

Now, anyone who has seen or read the news recently will know that serious youth violence such as knife crime is once again making the headlines, not just in London but across the country, with some people describing it as an epidemic.

In some parts of the world, so I’m thinking Chicago in the States and also Columbia and Scotland, they’ve transformed the way they look at violent crime, shifting away from just treating it as a criminal justice issue to taking more of a preventative approach and looking at the root causes of the problem.  And this has become known as the public health approach.

In England we’re also now starting to look at the issue in this way.  So, in this episode we’ll be looking at violent crime and the impact on the health service as well as unpacking what it actually meant by a public health approach, and to help us with this I’m joined by some incredible guests, who are experts in the field and have been working tirelessly to try to address the issue.

But rather than me introduce them, I’ll let them introduce themselves.  So, let’s start with you Martin, can you tell our listeners a bit about who you are, what you do and how you became involved in this work?

MG:    My name is Martin Griffiths.  I’m a Vascular and Trauma Surgeon and I work at the Major Trauma Centre in the Royal London Hospital and I have been for quite a long time.

I suppose my interest in violence comes from my background really, friends and family being hurt and murdered etc. and during my training and practice I realised that as a trauma clinician we had a problem with readmission in violence and we failed to support our society and youth.  So, I put in place some programmes and worked with community ambient bodies to try and move that agenda forward.

And in my role as a Lead for Trauma Surgery, I’m trying to introduce a public health approach to bigger institutions and the NHS in general.

HM:    Great, thank you, and I’m sorry to hear about your personal experience of that, Martin.

Karen, please introduce yourself.

KM:    So, I’m Karen McClusky, alongside a colleague of mine, John Carnicon, we set up the Violence Reduction Unit in Scotland in 2003, mainly because we had had enough of investigating murders and we no longer wanted to see parents who were traumatised through the loss of a loved one, or indeed, start to jail or continue jailing people who were never going to see the light of day for the next 23/30 years. And we had the UN report that came out and said that Scotland was the most violent country in Europe and Glasgow was the most violent city, and it was time to do something different.

HM:   And it was incredibly successful, as I understand it?

KM:   Yes. Success is a strange thing.  When do you get too successful, you know?  Fifty murders in comparison to one hundred and seventy murders, it’s never low enough.  But we have reduced our homicide by 56% over the last 10 years and our violence by 57%.  We don’t differentiate between serious violence and violence because that’s just craned classifications, and so I don’t talk about serious violence I talk about violence.  It’s only a crime if you report it to the police and I deal with lots of unreported.

HM:   Okay.  Well, we’ll explore that a little bit later.  So, to start, let’s unpack the problem.  So, last month Sarah Thornton, who is the Chairwoman of the National Police Chief’s Council describes the current situation as an emergency and I know that the data is often disputed, I think in part because a lot of it’s not reported, there are some complexities around definitions, but I think even then the ONS, the Office of National Statistics has argued that even beyond that the issue is on the increase.

But I also think it’s important to understand the problem behind the statistics, so Martin what’s the situation as you’re seeing it in your day job?

MG:   So, my situation is slightly unusual in that I work in a hub for major injuries, so I see the worst of the worst injuries, and working in one of the four major trauma centres in London we will see the most significant injuries that occur in the region as well as people who present locally.

What we’ve noticed is a 20% year-on-year increase in admissions due to interpersonal injury and more importantly a decrease in the actual age of patients.  Our peak age is now 17, it used to be 27/28 about ten year’s ago.  And more importantly, increase in number of injuries per person, so multiple injuries, collective violence rather than individual violence and weapon of choices has changed, it has moved towards caustics etc.

Now, I know you can count however you like, you can count police figures, but we know that only 25% of these sorts we see are actually recorded as crimes and you can look at London Ambulance Service numbers as well, or hospital admissions, but it doesn’t really matter from my experience as a clinician the numbers are increasing, the severity is increasing, the intensity is increasing.  And the youth of victim and perpetrator is the compounding factor that I find most concerning.

HM:   And are you also seeing revolving door syndrome in terms of people coming in and then coming in again?

MG:   The revolving door used to be a feature of our practice before we instituted the programme that I help set-up and we saw a 35% readmission rate within three or four years of initial injuries.  Some guys would come back with the same ID tags from the previous admission.

So, one way of tackling that was to try and look at the problem differently.  We put together a programme working with St Giles Trust and case managers looking at our patients and we were the first unit to bring in a ward-based programme that offered support, not just in the unit and meeting you at the front door, but actually supported you back into the community and got a relationship with you, your family and with the environment around you.

And we found remarkably, that the intervention as such reduced aberrant behaviour on the ward, it decreased admission to spectacularly low levels; 1% rather than 35% and our young people who had been under our care, changed from being violent and aggressive outsiders to being inclusive, inquisitive young people who wanted to get on with their lives and engage with their families.  And it’s an amazing change.

HM:   A total transformation,

MG:   Absolutely.

HM:    We’ll come on to the St Giles’ work in a little bit, but just before we do that, Karen, tell us a little bit about the problem you were seeing in Scotland when you started with the Violence Reduction Unit.

KM:    Well, interestingly not that different from what Martin was saying.  I have really close relationships with some spectacular trauma surgeons, I was an ex-nurse.  I worked in the emergency rooms and Alistair Ireland and Rudy Crawford, who were trauma surgeons within Glasgow Royal Infirmary, really just, I used to go up there, they were constant stabbings.  It was awash, our murder rate was really through the roof and the emergency rooms were passive receivers of the injured.  They couldn’t stop anybody coming through their doors.  And people were waiting for hours and hours, people with fractured necks of femur, and they were waiting because, of course, as soon as you get a young person or anybody that comes in with a really traumatic injury, they go to the very top of the list.

They take incredibly skilled surgeons, they take up ITU beds and so there were secondary victims as well, so people get bumped off lists.  And we had just had enough.  I talk about it; we had a 16-year-old boy who had been stabbed and he had pretty much bled to death in the gutter and this elderly woman had come out and she’d cuddled him whilst he died crying for his mum.  And I thought this is it, this is a Rosa Parks moment, where people just stand up and say this is it, we’ve had enough.

And nothing happened.  We’d just become immune to it.  And someone had said, I’d spoken to them about it and someone had said he was only he was ever going to be.  So, they made a value judgement about a young boy-

HM:   Given up on him.

KM:    From an area of poverty who had, we think that life chances are created equally and of course, they are not.  And so, we thought, we just had a zeitgeist.  I talk about this frequently, we had a zeitgeist in Scotland, I had the surgeons and we’d had enough as well.  I was in the police.  We had a 98% detection rate for murders, it was pretty easy; DNA, all these advances, we had it incredibly easy but we had prevented not very much.  And we had a fabulous Chief Constable called Sir Willie Rae at the time who just said go and do something different.

HM:   So, criminal justice alone wasn’t working?

KM:    Absolutely not.  I mean it’s easy to fill the jails.  You’ve done it down in England and Wales and we’ve done it up there, and frankly if that worked, America would have no crime, it just doesn’t work.  And the people that I was dealing with didn’t care about death at prison because their families were littered with it.

HM:   It’s not a deterrent.

KM:   It’s not a deterrent.  And so, we really had to unpick it and it was terrifying because you’re starting something completely different and re-framing it from a criminal justice to saying how do we then prevent it and utilising a sort of public health preventative approach.

HM:    So, there’s been a lot of discussion about taking a public health approach to tackling the issue, so starting with you Karen, in your view, what is a public health approach to violence?

KM:    It’s just a societal approach to tackle a problem.  And we used a very, it’s incredibly simplistic really, we looked at the surveillance about what was the skill of our challenge and through contact with our hospitals and some of our spectacular medics around Scotland, we managed to really look at the size of the problem that we had and some of the issues.  And we knew all the risk and protective factors, but what we didn’t know about was ‘what worked?’, ‘what worked to reduce this?’ and that is still an ongoing challenge.  We got loads of things wrong.  And then at scalability, how do we scale things up?

And we just started from then.  It took us along time really to really just do that piece of surveillance work in the first place, because the worst thing that you can do is just start off without really understanding the scale of your problem and involving those who are most involved in it and affected by it in your decision making.  So, I probably have got a team of people, I employ lots of people who have got lived experience and they absolutely shaped to what we were doing and were part of it.

But it’s long-term.  I think people think that it’s a miracle cure and of course, there is no miracle cure.

HM:   Yes.  One of the concerns I have at the moment, certainly in England, there’s been a rush recently to embrace the public health approach by government.  The approach has existed in the literature it’s been advocated by the World Health Organisation for some time.

MG:   Public Health England about 10 years ago.

HM:   Public Health England, the Department of Health published a document on it in 2012 and all of a sudden in 2019 or 2018 we’re seeing a strategy and people talking about it at national government level.  What do you think is going on there in terms of this sudden interest?

KM:   Do you know it’s really interesting, you know when I talked about this zeitgeist, sometimes you need a crisis to start people thinking differently.  Because what we’ve done so far hasn’t achieved the scale of the change that we want.  So, I think they’re starting to look at other opportunities, the challenges, I’ve been doing this solidly from 2003 and there’s tens of thousands of people right alongside me who are delivering this too.

There is nothing short-term, it’s taken 16 years for us to get to this stage, it has been relentless and I think that whilst people are quite starry eyed and they mention public health, they are less interested when I say well, it’s going to take you a decade/fifteen years really to really drive it down.

That’s not to say you can’t get short-term impact, you can, but to do the sort of primary, secondary and tertiary prevention and changing all the public norms, the social norms that go around this is a long-term endeavour.  And it will go beyond the political objective.

HM:   Exactly.  It doesn’t fit within their neat political cycle.  But Martin, what were you going to add?

MG:   To me, it’s very obvious why things have changed.  We started killing the right people.  When they killed poor, disempowered non-voting, unimportant people in Scotland and the poor of London it was just numbers.  It didn’t really matter.  We didn’t kill the right people.

HM:   They were stats.

MG:   When it killed the right people, like HIV, suddenly it became an issue.  And when county lines became an issue, why is county lines an issue?  It’s not because the same people are being killed, they’re being killed close to where you live, not being killed in Hackney or in Glasgow, they are being killed close to where you live.

HM:   And when you say the right people, what do you mean?

MG:   So, I mean it starts to, when it’s the innocent blue-eyed girl scout, that is an issue and that tragedy that affected that child and that family is the same for everybody else, but the equality of victimisation is very, very different.

HM:   And it propelled the issue further didn’t it into the media focus, political focus?

MG:   You see what you see anywhere in life.  When you see something that you recognise, somebody you can picture, your child, your friend, your family member, your neighbour, seeing that fate you change your attitude about things.  And I think when politicians started to realise that this was not going away, the numbers were going in the wrong direction, it was starting to kill constituents and started to affect, the public’s view on their own safety, not on this, on their own safety, things had to change.

HM:   And Martin, the unit that you’ve set up at The Royal London kind of takes a public health approach itself to the problem, what resistance did you face, or did you, when you were trying to initially set it up?

MG:   It was really interesting actually.  The first thing I faced was indifference, because we were treating the unloved, the difficult, angry young man who got stabbed who would come back again; frequent flyer, and they had no value and their families were lower-than, their mothers were terrible people and their fathers were absent.  That was a general belief system.

HM:   So they’re dispensable?

MG:   They are valueless, they are dispensable.  They are disposable individuals. So, to change the culture, great hubris about clinical care.  We’re awesome at treating trauma patients, but treating the families of the injured patients, big issue there.  And what I said I wanted to do something about, I wrote a document ten years ago about trying to reduce violence in our community, and I was politely patted on the head and told to put it somewhere, it would be okay.

And it wasn’t until we started to engage with those sets with St Giles Trust and write business cases and plans, that I convinced my colleagues it was worth a go and I had very, very very strong leadership and support from the Trust and from my consultant colleagues who embraced this policy, and decided to give this thing a go on our ward because this is a ward that’s used to doing trauma really, really well.  And to introduce a group of case managers who aren’t clinicians, who aren’t law enforcement, who have no tangible skills to see the most vulnerable patients and allow them to dig into their practice is a huge ask.  But the transformation in attitudes and behaviours by creating a longitudinal nurturing bond with these individuals and by supporting not just the patient’s clinical care, but their social care and continuing that care into the community for six months resulted in nothing short of a cataclysmic change in their lives.

And our service changed because of it.  We changed our culture, our attitude towards individuals, all of our patients young and old, injured, non-injured, domestic abuse, interpersonal injury, we changed our attitudes completely and we started to look after people.  We went back to doing what we’re supposed to be doing, not metrics, not algorithms.  We are in the health care business.

HM:   And outcomes.

MG:   And we are here to help people, be that physical, be that operation, be that financial, be that supportive, it’s about supporting capacity aspiration, not resilience, because life is hard enough as it is, that’s another label.  What you need is someone to listen to you, to support you, to understand your situation and to help you move things forward.

And by doing that, forget the label.  By doing that and doing our jobs properly and embracing the whole ugly task of trauma, not just the cutting, we made a massive difference.

HM:   So, I heard you say there about forget the label and I guess the kind of essence of a public health approach being embracing the ugly task of trauma, if you were to break it down, what are the core elements around what is a public health approach, what would you say it is?

KM:   Well grief, that’s a very difficult question because it’s so complicated.

We absolutely deal with the tertiary and Martin has absolutely explained about those who come to us.  So, I deal with lots of people who offend as well, in terms of violence, but then also dealing with those who are victimised and it’s interesting that we love to have victims and offenders, we think they’re separate groups and of course, they are not; they’re a victim one week and an offender the week next.  They are a patient, for me they are not a suspect.  And so, trying to break that down.

The second prevention for us was about targeting those who might be at risk.  They are not hiding.  It is incredibly easy.  We promote a zero-exclusion policy in our schools in Scotland, transformed some of the exclusion policies.  Glasgow has reduced their exclusions by almost 80% and what we see is one less kid you have out of school is one less kid I’ll not have in jail.  It’s a really, it’s trying to keep kids in school, and then that primary thing, supporting parents and all parents to give their kids the best start in life that they can.

And really just about wellbeing, because for wellbeing you need your life to be predictable, understandable and manageable and to have a sense of hope.  And for so many of the people that we serve, and we do serve them because both Martin and I are public servants, their lives aren’t that, their lives are in chaos.  And they are worried about getting stabbed.  They live a life of their cortisone levels and their stress levels are through the roof.  They are living lives that you and I don’t live and you need to understand that, that side of it.

MG:   I think it is true.  I mean we’ve done a lot of work on certainly prevention with the courts looking at young boys and girls who are at risk of, want of a better phrase, gang entry.  Crime prevention in schools and going down to PIUs and going down to primary schools and talking about lifestyle and careers and talking to parents about being parents, about reading with your children, understanding why it’s important and learning to read together, both parents and children and getting passed that issue about the resentment that people have about their previous experience in life.

Now, the pillars of society are law and law enforcement and you can’t have laws without law enforcement.  And there’s health care and there’s education, social services, and these are all agencies that are important, but on an individual and on a community basis there are things that we can do improve those sorts of things, but we can’t change the hard metrics, we can’t change the resource in lots of ways.  We can redistribute things more appropriately and allow access, but what we have to do is empower our population to make sensible choices.

HM:   So, one of the things that I’ve heard applied to why this is treated in part as a public health approach is this epidemiological approach, so really getting to grips with the root causes, looking at the data, which is why the data’s so important.  Do you both agree with the description of violence as being like an infectious disease, an epidemic, is that how you see it?

KM:   Do you know it’s an interesting paradigm.  I see clustering in areas, so just like a disease model.  We’ve not got to epidemic levels, although I’m sure that other people might disagree.

When I speak to people you can see things like those related responses, how many times people are exposed to violence over the course of a lifetime.  So, it does apply to it.  I know it’s not an infection, I know there’s no vaccine, but it is a really interesting way to try and change some of the paradigm that people see it, because people occupy sometimes opposing model universes.  They want you place it out of existence and of course, that’s because we’ve framed this as a criminal problem.

HM:   And those people as evil.

KM:   And those people as evil.  And that is incredibly damaging and actually inhibits us changing this.  So, changing the paradigm invited everybody else in.  So, I worked with the most spectacular maxillofacial surgeons because we have a huge history of serious facial injury in Scotland.  Quite unusual in comparison to London, I think.

There’s a bit of history and culture there and so trying to frame it like that was really interesting for us, and it absolutely shifted it in the minds of the public, and indeed the press.

Because I needed to get the press on-side, because I needed, so instead of them putting a horrible picture on the front and saying he’s just bad and he’s going to jail forever, we started to get them to speak about backgrounds, because every person that I meet in jail their story starts you see when I was 5, you see when I was 7, see when I was 8.

HM:   And this is like the adverse childhood experience stuff as, well right?

KM:   Indeed.  And whilst there’s loads of real argument about that, it is fundamentally about trauma and then how that manifests itself later on.  It’s not to say everybody will be affected the same, but it’s that understanding not that what’s wrong with you but what’s happened to you.  And I think that’s a great question to ask for anyone.

And my colleagues in medicine and nursing and all the allied professions have been spectacular about it because the one thing the people that I serve they really like health, they trust health, they have a relationship that perhaps I wouldn’t have and that what happened to you has been probably the biggest thing that we’ve really, and that’s been a real sea change for us in Scotland.

HM:   Yes.

MG:   I really struggle with this infectious disease paradigm because the people we serve are not infected, they are not diseased, there is nothing wrong with them, I hate the them part of it.  And it’s easy to medicalise it.  We can frame it as a disease and then we can empower ourselves to think about it in that way.  We can look at the data dispassionately about numbers rather than people because if it actually was about somebody having a horrible life and being abused as a child, that would turn you off the whole problem.  But looking at it as a number, as a data point is making it much easier, and I can appreciate the power of that model, but I struggle with the way it dehumanises what is entirely an entirely societal problem.  And I think we need to be brave enough to feel the pain.

HM:   And to feel part of the responsibility.

MG:   Because we are all responsible.  We are the people who close our curtains and walk away from these people, who don’t talk to these young children who are crying out for support.  They don’t get it at home, they’ll find their education on the street.  And we have all, all of us, turned our back on that skanky young person who is scaring you a little bit on the tube or whatever, you wouldn’t talk to them and you would avoid that kid, want that kid put out of your class because he’s disrupting your kids sat there.

HM:   Isolate the problem.

MG:   Well, cut it out.  Cut out the badness and move forward.   But then you have the fear, don’t you, that either you’ll be affected by it or it will infect your children.

HM:   Contamination.

MG:   That’s it.  And suddenly we have this us and them scenario again, which has reinforced this.  We should embrace.  We should embrace and accept.

This is a part of our society and we made this problem, either actively, by doing things, or by passively by allowing people to make the changes in our society that disempowered our community.  We stopped caring about people.

HM:   So, I take it that both of you are, in your own way, advocates of the public health approach.  I know there’s some opposition to the approach in particular and I’m not sure that this is fair, some people arguing that it’s a soft approach and that it should be treated solely as a criminal justice issue.

Just briefly, what would you say to that accusation, for you?

KM:   Well, I’ve been in the police 23 years and you’ve got one of the highest prison populations down here, as have we in Scotland, so we’ve not done that well and that’s my role now is to try and change that as well.

It doesn’t work if you just look at it as a crime because you just have to wait until the victims arrive at your door and then you do something.  You can’t police it out of existence because we’ve tried that, we’ve had some of the best of policing.  I know that’s slightly contentious, but over the years and I think some of the Scottish policing models, we were very engaged with communities, it hasn’t delivered the change that we want.  We need to do something different.

And who is going to argue against prevention?  I would rather prevent a murder any day than detect one, I really would.  I don’t want to go and see another victim’s parents.  I had people last week.  I don’t want to meet them and I know I will, but there is no joy, there is no joy in that and all the television programmes that glamorise it and glorify it are just toxic.

MG:   Monstrous, it’s monstrous.  And you’re right, they do glorify the macabre.  If it worked then America would be safe, as you said.  And we can’t police it out and we can’t kumbaya it out and we can’t, one single arm or treatment or intervention is not going to work.  It is about embracing the problem and understanding the problem and living with the problem and understanding that we’re going to have to change the attitude of our entire society.

And in a compassionate society, which is resourced, okay, we should do our best with our weakest.

HM:   So, you mentioned resourcing.  But in terms of impact of cuts to local authority services and their budgets, how important are those services and funding in terms of making this stuff work?

KM:   I often talk about smart justice.  I don’t talk about hard or soft.  The government kick in terms of how they slice and dice it, doesn’t get any bigger just because you salami slice it.  I think what the opportunity of doing a different approach gives us is trying to invest in things that work and putting the money there.  I will make myself incredibly unpopular now.  In 2008 and 2007 when we had loads of money, people were throwing money at you, we didn’t solve this either, certainly not in Scotland and I know that the challenges in London have got worse all the while.  It’s where you spend your money that’s really important.

People are always saying to me ‘oh, can we commission services?’, can we decommission stuff that doesn’t work, because we do lots of things that don’t work?  And we need to fund the right thing with a good evidence base, do a bit of innovation where it’s needed, but this should be the biggest thing, really exercising governments at a very top level.  And I know it isn’t right now, but it absolutely should be.

People are dying in your street; it requires resource and appropriate funding and long-term funding.  Not year-to-year which is what lots of our third-sector partners who do loads and they’re trying to survive on a shoe string and that’s just not possible.  And particularly if this is long-term, you need to commit to 15, 20 years.

MG:   And that is the problem.  A 3-year funding cycle for third sector or 4-5-year public cycle is never going to resolve the problem.  Their visible quick wins, that’s why stop and search and S60s are prevalent, but we’ve got to invest in prevention.  And the solution lies in childhood and parenting in communities and we’ve got to build those strong communities and we have to go back to rebuild, we’ve got to sow the seeds in the soil, we’ve got to support it, we’ve got to create communities which are effective and supportive.  And then they will police, they will support themselves.

We don’t need to institute martial law in areas of poverty, we need to actually decrease poverty and allow people to find their own way in a supportive and understanding society.  And the more we polarise our opinions, the more likely we are to find ourselves in a worse place than we are right now, where these hard opinions based on zero logic, okay, both the left and right of the argument make no sense.  And it’s about negotiation and agreeing to disagree.  We’re in times where the art of compromise is dying.

HM:   Yes, absolutely.

MG:   And we need to compromise on our own hubris and trust the data.

KM:   Can I just say it’s really interesting though, I often find the truth doesn’t set you free, alas.  It’s saying to people that it’s £40,000 a year to keep someone in jail.  People will stay just build more jails.  Let’s just jail them.

And look I’m no apologist, we need to jail those we’re afraid of, but not those we’re mad at.  And we need to prevent much more, but there are people who some really dreadful things and for the protection of the public, need to be in secure establishments and we need to try and rehabilitate them.  But let’s not kid ourselves that we’re not spending lots of money in a criminal justice system that’s not delivering the outcomes that people want, so we need to shift it elsewhere.  There needs to be some justice reinvestment and that might be to health and to early years and to other places, and we might just need to dry our eyes because it works.

HM:   Sajid Javid the Home Secretary has recently launched a consultation into a new legal duty that is intended to support a multi-agency or public health approach to preventing and tackling serious youth violence, and that would involve data sharing across different public service professionals including health professionals, teachers and others.  Martin, what do you think about the duty and whether it’s right to be asking health professionals to report over and above their existing safeguarding duties?

MG:   It’s a difficult one.  I think we know that data is hugely important, but the clinician’s role and their place in society and with the public is paramount.  We are a trusted profession.  People invest their time and effort and their belief and faith in us, and if we destroy that faith and transfer information appropriately, we lose that relationship and we lose the one bond between society and population that is true and effective.  And if we use that clinician anchoring point, what have we got left?

I absolutely, absolutely believe it’s important to share data.  We can anonymise it; we can bulk it, we can look at traffic data, that’s not a problem at all.  We can use that information to put in place great prevention programmes and look at metrics and look at how systems are working and, in the future, we’ll have an incredible amount, if we work with AI to help us predict models of delivery of care and preventative options.  But I’m really, it’s a slippery slope, about reporting things beyond what I think is appropriate.

It will require very careful negotiation between health care professionals, law enforcement and more importantly, the community about what is fair, what is just and what is appropriate.

HM:   Yes.  And how they see you, because I guess it does kind of present, in some ways, an ethical dilemma to health professionals.

MG:   Well, yeah. If a patient has got a gun in their pocket and a load of drugs, that’s a different issue to somebody who admits to know something about an issue that is not related to this particular admission but might be useful elsewhere.  And I do not want to lose my patient’s trust.

HM:   Yes, otherwise they stop coming.

MG:   Not just them, but their children and their family become unwell and then they present to me later with other injuries.  It’s not just trauma, it’s medical problems. And if you stop trusting your GP, and you stop trusting your health visitor and you stop trusting your doctor, what have you got left?  And if you don’t trust the nursing and health care professionals around you, where do you go to for advice?  Where can you ask confidential questions?

HM:   And Karen, as part of your work when you were setting up the Violence Reduction Unit, did you have a data sharing duty in place?

KM:   Yes, anonymised.

HM:   Anonymised.

KM:   But not a duty.  We worked with consultants and others and we anonymised all the data.  To be honest, I wasn’t interested in knowing the identify or whatever else.  I think Martin is absolutely right.  People need to trust the health services and Martin can intervene, he knows that person and he can intervene, and he’s doing that right now.

HM:   And you already are, yes.

KM:   And it’s about you can’t silo services anymore.  That’s set up for 1983.  It’s 2019, we need to look at the problem and arrange it differently.  And what we’ve got at the moment is an ingenuity gap with all the problems that are coming and our ability to solve them, and that bit in the middle is that ingenuity gap.

And so we’re going to need to change and enable partners and partnerships is always just about working with great people, to intervene at that teachable moment when someone’s on their bed, who is in a cell, who is in a jail cell, to do something different.

So, no we didn’t have a duty and I’m not sure that we would particularly have wanted one.

HM:   Yes.  So, to end, we’ve been talking what can be done from a health perspective and taking a public health approach to tackle violence.  What is the one thing that our listeners, many of whom are health professionals or working in local authorities on social care, in your view, could do to support this agenda?

KM:   I would say look at your own practice.  Everybody can do something.  And not just as a health professional, just to be a good human being.  I think it was Adam Smith in 1774 said that ‘empathy was a glue that kept society together.’  I think if we thought about that just that little bit more, we’d all be in a better place.

MG:   Listen rather than preach.  We need to listen, not just to what hurts, what makes the pain go away, but what made the pain start in the first place.  Why you are there in the first place?  Why you’re crying in your bed at night, why you’re wetting yourself, why you’ve come back to see me for no good reason because there is a problem there that we can unpack.  And if I listen to you, you will tell me because you want to tell me.  And I want to hear now.

So, we need to stop preaching.  Stop transmitting, start receiving because that is all there for us.

HM:   That’s really powerful.  Both of you thank you so much for joining us today.

Well, that’s it from us. Thanks for listening and if you’ve been affected by any of the issues raised in this episode, there are a number of organisations that can offer advice, information and support.  And you can find information about those organisations in the show notes for this episode.

As always, please subscribe, rate and review us.  And if you have feedback or ideas for topics, you’d like to hear covered in future episodes, then please get in touch, either on Twitter @TheKingsFund or at my account @helenamacarena.

Hope you can join us next time.